Transcript PUTTING IT ALL TOGETHER: The Building Blocks to Create the 21st Century Health Care Delivery System Jerome H.

PUTTING IT ALL TOGETHER:
The Building Blocks to Create the 21st
Century Health Care Delivery System
Jerome H. Grossman, MD
Director, Health Care Delivery Policy Program
Harvard University JFK School of Government
June 2004
Roller Coaster Ride
1993-1997
1998-2003
Tightly Managed Care
HMO Backlash
Preferred Provider Orgs
0% Medical Inflation
Deep Cuts in Medicare
13% Medical Inflation
4% Unemployment
5 ½ % Unemployment
Balanced Budget Act
The Next Blow
Myth of medical safety and quality burst:
2001
To Err is Human
100,000 deaths from errors
2001
Crossing the Quality Chasm
2003
Less than 50% of chronic care patients
receive “best demonstrated” practice care
What Hasn’t Happened
Medical Injuries Cost
Billions Every Year
Researchers studying healthcare quality have concluded
that medical injuries caused
during hospital stay kill tens of
thousands of patients annually,
requiring at least 2.4 billion
extra hospital days resulting in
potential medical charges of
$9.3 billion.
The work underscores both the
scope of the problem and the
relative lack of action in solving
it. In 1999, for instance, the
Institute
of
Medicine
recommended the creation of a
“nationwide
mandatory
reporting system” for medical
errors. That hasn’t happened.
Very little progress has been
made.
Source: Wall Street Journal
Very little progress
has been made.
The New “New Thing”
Preliminary Shift to Consumer
2001
2003
2004
“Consumer Directed”
Health Care
HEALTH
SAVING
ACCOUNTS
Medicare
Modernization
Act
The Building Blocks
Future Hopes
Financing
Existing “Trends”
Purchasing
HEALTH FEDERAL RESERVE
Health Value
Added Tax
Universal Health
Plan Voucher
Based on Clinical Condition
Regulating
Cash
Account
Providing
SEPARATE FEDERAL AGENCY
License and
Monitoring
(Consumer Defined Plans)
Catastrophic
Account
Behavioral
Economics
Monitoring
Safety/Safety
Improvement
HSA
Vocab/Reporting
Licensure
Transparency
Arbitration
Malpractice
Productivity
Network
Creation
Systems
Management
Financing
HEALTH FEDERAL
RESERVE
Health Value
Added Tax
Universal Health
Plan Voucher
Based on
Clinical
Condition
Monitoring
FDA
Productivity
Clinical Conditions
Regulation
SEPARATE FEDERAL AGENCY
Safety/Safety
Improvement
Vocabulary and Reporting
Transparency
License and
Monitoring
Licensure
Arbitration
Malpractice
METAPHORS
FAA/NTSB
FASB
Federal Reserve
RESEARCH
•Performance Based Regulations
•Management Based Regulations
•Risk Based Regulations
SEC/NASD
Purchasing: From Managed Care to Health Savings Account
From Defined Benefit to Defined Contribution
Government Corporation Individual
Catastrophic (Risk)
Cash Account
HSA
401K
Rollover
Portable
Behavioral Economics
“Libertarian Paternalism”
•Carve In for Chronic Disease and
Means Testing
•Reduced Payment for Good Health
and Disease Prevention
“A”
Perfect Market
• Large numbers of consumers and firms
• Free entry and exit
• Marketability of all goods and services including risk
• Symmetric information with zero search costs
Key Failures in Health
• Asymmetric information/costly search
• Marketability of risk
Bearing More of the Burden
35%
12.0%
10.9%
8.6%
9.5%
20%
9.1%
9.6%
25%
12.8%
30%
19.5%
18.0%
17.1%
16.8%
5%
16.7%
10%
15.5%
15.7%
15%
Employees annual
healthcare costs,
paid by . . .
Employees, out of
pocket
Employees, payroll
dedcution
20
04
pr
oj
e
ct
io
n
20
03
20
02
20
01
20
00
19
99
19
98
0%
Overall annual healthcare costs rose from about
$4,000 in 1998 to about $7,000 in 2003, and are
projected to rise an additional $1,000 in 2004.
Source: New York Times,
Hewitt Associates
The New 401(HEALTH)
401(HEALTH)
Corporation
Government
Self
Defined Contribution
Must buy catastrophic insurance
Risk Tolerance
“Auto Insurance Points”
+ for healthy behavior
+ for preventive tests
Medical “Savings Account”
+ for chronic disease
compliance
Rollover
Result – Lower “rates”
next year
Portable
Catastrophic Insurance
x 1,000,000 lives
Epidemiologic (Incidence & Prevalence)
x
Predictive Risk Modeling (Disease Severity and Comorbidity)
x
Normative Resources (From Productivity)
=
Outcomes (Outputs)
•Technical
•Functional
•Trust
•Service
Distribution of Responsibility
Populations
Providers
“Act of God”
Deterioration
At Risk High Cost
Disease
Chronic Disease
Acute Care Cured
by RX
Acute Self Limited
At Risk
Disease Prevention
Public Health
Productivity: Quality AND Cost Improvement
Clinical Condition
“Input”
Quality
“Output”
Arthritis of Hip
- with surgery
- without surgery
• mild
• moderate
Medical Surgical
Rehab
- Technical
- Functional
- Trust
• severe
- Service
All Resources ($) Used
Providing: Complex Interdependent Systems
Data Exchange 7 x 24 x 365
The Patient
Customized Protocol
Front Line Team
Flexible Management
Organization
Post Introduction Surveillance
Bioterrorism
Regulation
Environment
Productivity
Reengineering
Human Factors
Job Redesign
Organization
Engineering in the Service of Medicine
Two Major Interconnected Opportunity Sets for
Engineering and Medicine
1. Information and information/communication technologies
and associated research to advance connectivity,
information flow, coordination.
2. System design, analysis and control tools & associated
research to advance understanding of processes and system
interactions; and improve/optimize dimensions of system
performance in face of constraints.
Information and
Information/Communication Technologies
Information and information/communication
technologies and associated research to advance:
• Connectivity
• Information flow
• Coordination
For Example
Wris t
Blood Pressu re
Mon itor
120
80
Il lustration of a se lf contai ned, wrist worn bl ood pre ssure
de vice si mi lar to that marketed by O MRO N Inc (~$75 US)
Data Monitoring
PTT
Signals f rom the ECG and pulse pressure changes provide different
physiologic inf ormation and can be used together to gain additional
data such as the pulse transit time (PTT). Rapid pulse timing can be
from a pulse pressure monitor or from a pulse oximeter in the
ref lectance mode or conventional transmission mode.
Wireless Endoscopy
Capsule Endosc ope
11 mm x 26 mm
Data Recor der
with B atery pack
which can be
downloade d onto
laptop compute r
Antennae
Wi re le s s e ndoscopy usi ng a dis posabl e s e lf containe d cam e ra in an
avai labl e capsul e (11m x 26mm ) whi ch is tracke d by an ante nnae
array faste ne d to the torso (GIVEN IMAGING Ltd.,
http://www.gi ve nim agi ng.com/usa).
Biomonitoring Techniques
Biomonitoring
GPS
A. Chemistry chip pendant
(saliv a sampling )
B. Skin electrodes
A
(cardiac & respiratory)
B
C. Strain guage & Heart Rate Monitor
C
D. Accelerometer
D, F, H
D, E, G
E. Phone / Camera / GPS
F. Chemistry
(p02, pCO2, suga r)
G. Local area network
H. Pulse Pressure
D
Keeping Patients Connected
Source: Boston Globe
Every Home an ICU
Source: Boston Globe
Systems Design and Implementation
System design, analysis and control tools and
associated research to:
• Advance understanding of processes and
system interactions
• Improve/optimize dimensions of system
performance in face of constraints
Integration of Multiple Subsystems
PCP
Triage
Lab
Surgery
Admitting
ICU
ED
Patient
Ed.
Nursing
Library
Post-OP
Specialist
Health Care System Quality
Process
•Protocols
• Procedures
• Best Practices
Patient Inputs
• Severity
• Comorbidities
• Age/Sex
• Socioeconomic Status
• Compliance
• Genetics
• Expectations
• Attitude
•Safety
• Service
• Timely
Patient Outcomes
Infrastructure
• Credentialing
• EMR
• Staffing
• Facilities
• Volume
• Integrated Practice
• CPOE
• Educational Environment
• Teamwork
• Innovation
• Patient-Centered
• Systems Engineering
• Mortality
• Morbidity
• Functional Status
• Quality of Life
• Cost of Care
• Satisfaction
Source: Jim Naessens, Thesis Work
The Tools of Systems Engineering
Systems Design
• Quality, Function,
Development
• Human Function
Engineering
• Failure Mode
Effect Analysis
Systems Administration
• Modeling and
Simulation
• Enterprise Management
• Knowledge Discovery in
Data Bases
• Predictive Risk Models
• Individual Decision
Making: Optimization
• Distributed Decision
Making
Systems Control
• Statistical Process
Control
• Scheduling
Systems Engineering: Research and Development
Education and Training
Systems Based Team Care
Clinical Conditions
Systems Engineering
Genome
Systems Biology
Suggested Readings
For more information, see the website for the
Harvard/Kennedy School Health Care Delivery Policy Group
at http://www.ksg.harvard.edu/cbg/hcdp/
Suggested readings include:
1. “Putting It All Together” under
“Research Projects”
2. “The Numbers”